Tips to Help Win Your SSDI Claim: Setting Up a Helpful Medical Record

chronic pain patient

You are never “OK”, “doing good”, or “fine”

The likelihood of your claim being approved will largely depend on medical evidence. Every time you go to your doctor’s office you are asked “How are you feeling today?” The knee jerk answer, “I am fine” or “I’m OK” can cause problems for your Social Security case. Your doctor could report your answer in their notes as “the patient is doing ok” or “he is feeling fine” or “he has no complaints”. You can’t go back and fix this.

If you were fine, you would not be seeing a doctor.

You should never say “OK” or “fine” or any other such words when you are asked how you are doing by anyone at a doctor’s office or hospital. 

You are the only one who knows exactly what you are going through and how you feel. It is vital that you report your symptoms, including any side effects you have from your medication to your doctor every time you see them.

You must be treated often

If your injury or illness is bad enough to prevent you from working, then it is bad enough for you to seek medical treatment. It is not enough to simply be diagnosed with a condition. That in and of itself does not help your claim. You should seek treatment as soon as possible. This is important, most of all because it gives you the medical care that you need. It also gives an official chronological record of your medical treatment, testing for your injury or illness, and your symptoms and limitations, which is important for building an SSDI case.

Follow reasonably prescribed treatment.

Follow the treatment your doctor prescribes for you. If you have concerns or questions about the treatment, discuss them with your doctor.

If your doctor tells you the treatment may not improve your condition, or could make it worse, you need to discuss the chances of success or failure of the treatment with your doctor. If the chances of success of a recommended treatment are high, and you do not follow through, this may cause a problem with your SSDI claim.

Explain your pain, symptoms, medication side effects, and other limitations in detail

Most people don’t describe their pain, symptoms, and how they affect their ability to function in adequate detail. The more specific you are when you describe your pain and symptoms, the more helpful it is for your claim. You should focus on describing the limitations that you experience in detail to your doctor/nurse, so they are put in your record. As you continue treatment, you should also note any changes in your pain or symptoms to your doctor.

Keep Symptom Logs

With some conditions, such as migraines, headaches, seizures, etc., keeping a log can help you document the frequency, duration, and other details of your symptoms which can help with your treatment and your SSDI case.

If you suffer from seizures, you should record the date and time of each seizure, the type and intensity of the seizure, how long it takes you to recover, and any other information relevant to each seizure. You should give your doctor a copy of your symptom log.

Keeping a record helps to support your complaints and the ongoing severity of your condition.

Consult a Specialist

Specialists are doctors who focus their practices on a particular area of medicine. These doctors have more expertise in certain areas of medicine than your primary care doctor. Depending on the condition, a diagnosis from a specialist can give a lot more legitimacy to your claim.

A good example would be Fibromyalgia. Most people get a diagnosis of the condition from their primary care physician. The diagnosis should be confirmed by a Rheumatologist. A Rheumatologist can perform tests that rule out other causes of your symptoms.

Call an SSD Lawyer

For more information on how to improve your chances of having your SSDI claim approved, connect with our office for a free consultation! Our experienced attorneys have helped hundreds of claimants secure the benefits that they are entitled to.

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